A structured narrative review suggested that tension-type headache may be better understood as a multidimensional condition shaped by interacting musculoskeletal, central neurophysiological, psychosocial, and lifestyle-related factors rather than by a single mechanism.
The researchers searched PubMed, Scopus, and Web of Science for studies published from 2010 to 2025, with earlier foundational studies included when relevant. They identified 412 records, screened 316 after duplicate removal, assessed 54 full-text articles, and included 32 studies in the qualitative synthesis. Included studies involved adult patients with tension-type headache diagnosed according to International Classification of Headache Disorders, second or third edition, criteria.
The review synthesized observational studies, experimental research, randomized controlled trials, systematic reviews, and meta-analyses. No formal systematic review protocol was used, no standardized risk-of-bias tool was applied, and the researchers did not perform quantitative pooling.
Across the included literature, musculoskeletal findings such as craniocervical muscle dysfunction, myofascial trigger points, postural factors, and altered motor control were associated with headache expression, particularly in episodic forms. The review also noted that electromyographic studies have demonstrated elevated resting muscle activity and impaired coordination even between headache episodes, particularly among patients with chronic tension-type headache. Some trials and reviews suggested that interventions targeting musculoskeletal dysfunction may reduce headache frequency or intensity, although the researchers cautioned that these findings do not establish musculoskeletal abnormalities as isolated causes of tension-type headache.
The review supported a continuum model in which episodic tension-type headache is more closely associated with peripheral nociceptive input, whereas frequent and chronic forms are more strongly associated with central sensitization, reduced pressure pain thresholds, altered descending pain modulation, and broader changes in pain processing. Much of the evidence for these mechanisms came from observational, experimental, neuroimaging, or broader chronic pain research, limiting causal interpretation.
Psychosocial and lifestyle factors also appeared to modulate headache burden. Perceived stress, anxiety, depression, coping strategies, occupational factors, sleep quality, physical activity, and chronic physiological stress exposure were associated with headache frequency, intensity, disability, or chronicity across studies. However, the researchers emphasized that these factors likely interact with peripheral and central mechanisms rather than acting as independent causes.
The proposed framework groups contributing factors into four domains: peripheral musculoskeletal factors, central neurophysiological mechanisms, psychosocial factors, and behavioral or lifestyle factors. Within this framework, patients may be conceptualized according to dominant mechanistic profiles—such as primarily peripheral, central sensitization–driven, psychosocially influenced, or mixed presentations—potentially helping explain variability in symptoms and treatment response.
The framework also outlined ways these domains could be assessed clinically, including cervical muscle strength and motor control testing, evaluation of myofascial trigger points, pressure pain thresholds or quantitative sensory testing for central sensitization, validated questionnaires for stress and anxiety, and monitoring of sleep quality and physical activity. The researchers emphasized that these assessment pathways remain conceptual and require validation before they can be used for routine clinical stratification.
The review also briefly noted transnasal sphenopalatine/pterygopalatine ganglion–targeted approaches as a potential complementary strategy in headache disorders, but the researchers described the evidence in tension-type headache as preliminary and exploratory.
The review’s limitations included the predominance of observational studies, heterogeneous study designs and populations, limited longitudinal evidence, absence of quantitative pooling, no formal systematic review protocol, and no standardized risk-of-bias assessment. The researchers described the clinical implications as hypothesis-generating and said future longitudinal and interventional studies are needed to validate the model.
“TTH cannot be fully understood as a homogeneous entity nor as an exclusively musculoskeletal disorder, but rather as a complex and multidimensional clinical phenomenon,” wrote lead researcher Ana Bravo-Vazquez, of the University of Seville, and colleagues.
Disclosures: The researchers reported no conflicts of interest. The study was funded by Fisiosur I+D under project number FS1TTH26. The researchers acknowledged using artificial intelligence to assist with translation and image creation.
Source: Journal of Clinical Medicine